A Handbook of Neurological Investigations in Children

Training of the young child or a child with a cognitive impairment begins with learning simple cause and effect, which can be trained using switch-operated toys and simple computer games.

Provision of equipment to enable people to access and use their social and physical environments effectively is a critical component of therapy for many people with cerebral palsy

1940s (Hari and Tillemans,1984). Conductive education is usually carried out within group educational settings with a focus on promoting independence. The fundamental philosophy of this approach is that movement problems are viewed as problems of learning. Therefore, proponents argue a learning process should be used to develop independence to the best of the child’s ability, without emphasizing movement quality. In therapy a major focus is placed on the child’s initiation, practice and participation in daily activities. Simple plinths, ladder-backed chairs and orthoses are the only equipment used in therapy. Like the Bobath approach, one of the difficulties with evaluating conductive education is that it has been adapted by clinicians over time and from person to person and there is considerable variability among clinicians about the extent to which other approaches should be incorporated into therapy. Effectiveness has been evaluated in four systematic reviews (French and Nommensen, 1992; Ludwig et al, 2000; Pedersen, 2000; Darrah et al, 2004). The overall conclusions of these reviews agree that the number of studies to have evaluated the effectiveness of conductive education is too small, and the quality of those that have been completed is too low, to make conclusions about the effectiveness or lack of effectiveness of conductive education.

Therapists use handling, positioning and guiding or facilitating movement to normalize tone and promote optimal participation. A goal of therapy is for the person with cerebral palsy to work actively towards what they can do with little help. These techniques are taught to parents and carers so that they can be used to carry out activities of daily living. The emphasis on positioning and handling is often valued by families. One difficulty with evaluating the approach is that it is not always clear what the Bobath approach really is because it has been adapted by clinicians over time and from person to person and there is considerable variability among proponents about the extent to which other approaches should be incorporated into therapy. Two well-conducted systematic reviews found no strong evidence that the Bobath approach, or NDT, is effective in the management of people with cerebral palsy (Brown and Burns,2001; Butler and Darrah, 2001). A more recent very small randomized controlled trial showed some support for the value of neurodevelopmental-based trunk co-activation to improve postural control and gross motor skills in infants with posture and movement dysfunction (Arndt et al, 2008).

Muscle stiffness, contracture, atrophy and fibrosis may interact with spasticity to produce ‘hypertonia’, which is the term often used to refer to the excessive resistance felt when the joints of people with neurological disorders such as cerebral palsy are moved passively. In clinical practice, it is important to distinguish between resistance due to spasticity and that due to changes to soft tissues, because the distinction has therapeutic implications in terms of the effectiveness of different therapeutic interventions. For example, anti-spasticity agents such as botulinum toxin A are only useful for true spasticity and not muscle contracture, whereas muscle lengthening procedures such as surgery are more effective if the person has muscle contractures or stiffness

Spasticity is one component of the upper motor neurone syndrome, and it is this damage to the central nervous system corticospinal (pyramidal) tract function, rather than spasticity per se, that is the cause of motor problems in people with cerebral palsy. Spasticity is ‘characterised by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks (phasic stretch reflex), resulting from hyper-excitability of the stretch reflex’ (Lance, 1980: p. 485). Spasticity therefore is present when the resistance to movement increases with increasing speed and when the resistance to movement differs with varying direction of joint movement (e.g. differs with flexion versus extension of a joint) (Sanger et al, 2003). In addition, spasticity is present when the resistance increases rapidly after a threshold of movement is reached – that is after the ‘catch’ is felt (Sanger et al, 2003).

Spasticity is present in 75 to 88% of people with cerebral palsy

The primary motor disorder of cerebral palsy is described in terms of the nature of the movement disorder and the resultant level of motor function. This includes identifying the presence of abnormal muscle tone and specific movement disorders.